Claims Credentialing Specialist

Job Title:         Claims Credentialing Specialist

Reports to:     Manager of Billing and Collections (AR and Claims)

Summary:  The Claims Credentialing Specialist researches the provider claim edits by reviewing internal rosters, state and federal rosters, and NPPE’s profile for accurate information. Coordinates any required updates needed with the managed care and WWT credentialing departments for review. Process claims once information is verified and updated by resubmitting all applicable claims.  

Essential Duties and Responsibilities:

• Collaborate with the Managed Care and Internal WWT Credentialing departments to evaluate provider-related claim edits and denials.
• Liaise with various departments and personnel to facilitate required provider updates for billing purposes.
• Monitor physician status until updates are marked as "complete."
• Maintain active rosters received from Payers and/or Managed Care department as a primary reference.
• Address claim edits and denials stemming from credentialing issues and generate necessary reports.
• Relay pertinent issues to the relevant credentialing departments and management.
• Audit credentialing work queues to ensure prompt release of charges held for pending updates in Epic and/or on the NPPES website.
• Resubmit all relevant denied claims upon completion of updates.
• Perform additional duties as assigned.

Knowledge, Skills & Abilities:

• Knowledge of collections, healthcare terminology and office procedures.
• Attention to detail with the ability to identify/resolve problems and document the outcome.
• Strong concise, clear written and verbal communication skills.

• Organizational skills – ability to multi-task and work independently.
• Solid, strong analytical and problem-solving skills.
• Goal-oriented – holds him/herself accountable to achieving shared and personal goals.
• Establish and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
• Establish and maintain effective working relationships with employees, departments, and external vendors.
• Maintains a high level of confidentiality.
• Advanced skills with Microsoft Office applications: Word and Excel.
• Excellent time management and workload prioritization skills.

Education/Experience: 

• Minimum two years’ experience in revenue cycle processes
• Ability to demonstrate problem solving, analytical, oral and written communication skills, and the ability to interact professionally with a diverse group
• Working knowledge of EPIC software desired.
• Exposure to provider enrollment or credentialing desired.
• Ability to engage in multiple initiatives simultaneously while working in a dynamic environment subject to impromptu changes in schedules and priorities
• Proficient in Microsoft Office applications, Outlook and Excel
• Strong initiative – establish goals and take responsibility for meeting them within defined timelines